The Road Ahead For Obamacare

I'm Michel Martin, and this is TELL ME MORE from NPR News. Coming up, we're in the thick of football season but increasingly, fans are worrying about how their favorite players are faring after their playing days are over. Now, there's a new plan to address that, and the head of the NFL Players Association will be joining us later in the program to tell us more about that - as well as, of course, his take on the allegations of bullying in the Miami Dolphins locker room. That's later.

But first, a look at that controversy over health care for the rest of us. In October, just over 100,000 Americans selected health coverage plans through those marketplaces set up as part of the Affordable Care Act. Now, that number was only 20 percent of what the Obama administration had estimated before the rollout. And what were first described as glitches back when the HealthCare.gov site first launched, seems to have turned out to be major technical flaws that have prevented hundreds of thousands of Americans from logging in and signing up.

Now, the president says he's got plans to address the problems. But to help us sort through where we are right now, we're turning once again to Mary Agnes Carey. She's a senior correspondent at Kaiser Health News. She's been guiding us through this whole process. And once again, that's a news service. It is not affiliated with Kaiser Permanente. She's back with us in the studio. Welcome back; thanks for joining us once again.

MARY ANGES CAREY: Thanks for having me.

MARTIN: So first of all, Health and Human Services secretary, Kathleen Sebelius, released the figures yesterday afternoon. Can you just help us break them down? Just tell us what we found out.

CAREY: Right. Of this 106,000 number of folks that have enrolled, they haven't necessarily paid for coverage - that's a one-month number for enrollment. About a quarter of those are through the federal exchanges. And we have to remember that the federal government is representing the health insurance marketplace for exchange in about 35, 36 states. That's a pretty low number for a pretty large number of states. Three-fourths of that 106,000 number came through the state-based exchanges. Those are only in about 14 states and the District of Columbia. So it underscores the problems with people getting onto the website - in the federal website, HealthCare.gov, and signing up. And the states tend to have a little less problem with that.

MARTIN: So there have been hearings on the Hill this week about the problems with this website. Have we learned anything new about why it's such a mess?

CAREY: We've learned that it is, like you say, such a mess, and it is extremely complicated fixes. We're hearing all sorts of phrases like, you know, we're working 24/7. It's not where we want it to be. They have talked about lists of hundreds of fixes that must be made. And so it's just this ongoing saga of, pretty much, why are we here? Why did it start on October the 1 if they weren't ready to go? Technical people are saying that they didn't necessarily anticipate all of these problems. So it's the same back-and-forth we've heard for weeks.

MARTIN: Has there been - and I hate to use this phrase 'cause it's such a cliche - but has there been any smoking gun? I mean, has anybody been able to identify a critical management fail, technical fail, administrative fail, leadership fail? Has anybody been able to identify some key to this whole thing?

CAREY: I don't think there's been any smoking gun. There was some debunking yesterday in a hearing. Some of the Republicans were insinuating that decisions about what to launch on healthCare.gov and what not to lunch were done politically and from the White House. Technicians from the Centers for Medicare & Medicaid Services and the Department of HHS had said that these were not political decisions. There's been a lot of wrangling there. But there's just this general understanding that they're in the middle of something they didn't anticipate - they being the administration - and they're working as hard as they can to dig their way out of it. But as we can see, this damage is coming day after day after day.

MARTIN: And if you're just joining us, we're talking with Mary Agnes Carey, senior correspondent at Kaiser Health News. We're talking about the challenges facing the Affordable Care Act, the rollout of this new program. Now let's get to the issue that I think has really captured a lot of people's attention, especially if you're somebody who's been affected by this. And a lot of Americans have been notified that they're being dropped by their existing insurance plans because those plans don't meet minimum coverage standards of the new health care law. And, you know, I think it is important to emphasize once again, we're talking about a pretty small part of the market.

These are generally people who do not get their health care plans through their employer, which is the majority of people. And it's people who don't get their plans through Medicaid or Medicare. These are people who self-pay, right, but it's upsetting. And President Obama had said from the start that people could keep their old coverage if they wanted to. He's apologized for that, but even some of his political allies say that that's not enough. Here's a clip of former president Bill Clinton talking about this.

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BILL CLINTON: I personally believe, even if it takes a change in the law, the president should honor the commitment the federal government made to those people and let them keep what they got.

MARTIN: Now as it happens, the president is expected to talk about this as we are speaking now. What can he actually do?

CAREY: He's expected to take an administrative action, which means it doesn't have to go through the legislative process on Capitol Hill. That would allow people who are in these plans to keep them for another year. The insurers couldn't sell these plans that are deemed not to be - they don't meet the standards of the Affordable Care Act. They couldn't sell them to new customers, and also insurers would have to tell people in these plans, these are your other options for coverage. And also, they have to explain to them what protections of the Affordable Care Act they will not have if they keep their current coverage that they would have if they dropped it and picked a new plan.

But, as you note, this is an effort to smooth out the problems, particularly political problems for Democrats on Capitol Hill, who have also told their constituents, if you like your plan, you can keep it. And again, to your earlier point, the individual market is about 14 million people. It's about 5 percent of the overall health insurance market. And within that 14 million, the estimate is maybe 2 to 4 million people have been getting these notices that say, your plan doesn't comply, and it won't be offered after January 1.

MARTIN: Can this be done - you're saying that the president says he can do this administratively. Is there also a legislative fix? Because we know - as we know, that there's a lot of churning on Capitol Hill around this. Are lawmakers also looking at a legislative fix for this?

CAREY: They are. The House of Representatives is scheduled to vote tomorrow on a bill that basically says, if you have your health insurance and you like it, you can keep it through 2014. This is a Republican bill - Republican-drafted bill - but it's been getting more and more Democratic support as Democrats who supported this bill facing midterm election in 2014, are worried about the problems with HealthCare.gov and wanted to offer some sort of answer to their constituents. This move by the president could mute that and take Democrats off that bill.

MARTIN: Now some Democratic leaders have spoken with the president in the past couple of days. Harry Reid, who's the Senate majority leader - as you know, that - you know, Republicans control the House, Democrats control the Senate - he says he feels, quote-unquote, very comfortable that the website will be fixed soon. And does that mean that the Senate is disinclined to take up this House bill, or what does that mean? Interpret that for us, if you would.

CAREY: Anytime you get into a legislative arena, where you're going into a law as big as the Affordable Care Act and make a change, it isn't like you can just go in and do what you want. People are going to want to amend that bill. It gives another opportunity to pick it apart, to try to make changes. They would like to sidestep any of that if possible. So if the president can get ahead of this momentum in the House - there's also Senate bills who did the same thing - that takes that problem off the plate for Harry Reid.

MARTIN: Now this may go beyond the scope of your expertise here, but does he in fact have the authority to do that? I mean, this has been one of the big issues that's been debated over the Affordable Care Act all along is, what does the president really have the authority to do?

CAREY: Well, that's the fight for the lawyers.

MARTIN: OK.

CAREY: And so once the president makes that decision, if - it wouldn't surprise me if it faced legal challenges.

MARTIN: Now let's talk about - in the last couple of minutes that we have left - we have about kind of four minutes left. I did want to talk sort of more broadly about how this issue is being received and what affect all these glitches are having on people's confidence in the law. I mean, one of the things that - there are questions about security issues. I mean, these days, people have become very aware of identity theft issues and so forth. And if there's security problems, that's the kind of thing that makes people not want to participate. People have been particularly focused on younger people who tend to be healthier. And advocates for both sides have been aggressively either urging younger people to sign up or urging them not to. Do you have any sense - or do we have any sense of whether all these kind of technical glitches have been a turnoff for the public? I mean, the fact that people aren't signing up, is it because they can't or because they're kind of turned off and they don't really want to, they're not as interested?

CAREY: Right. There's a few things to note. The 106,000 figure we had does not delineate by age, and to your point, getting the young and healthy people is critical because they'll balance the risk. So that's one factor. There's also a six-month enrollment period. There's no doubt that these numbers are not good for the administration's case for the ACA, but they say people have six months, and they hope to straighten out their glitches and so on. But I think it does - it is clear to note that people who really need this coverage, right, who are struggling and need it, they're going to hang in with all these bumps and problems and glitches. But other people may become frustrated.

They may be weighing this tax penalty that they face - $95 or 1 percent of income in 2014. Once they see a premium, if they think it's a cheaper route to go, they might simply pay the tax penalty, but then again, they won't have health insurance, which can present other problems if you do have, you know, major health problems. So this has definitely been a turnoff. We keep reading tons of stories and hearing about people who say, well, I called the 800 number, and someone said they'd get back to me and they didn't get back to me. Some people are encouraged to simply apply on paper. Secretary Sebelius was saying yesterday, you can go to the browsing function of HealthCare.gov.

If you see a premium from a certain insurer, you don't even have to go to the website to buy from that insurer, if you're not qualified for a subsidy, just go to them directly. But there's no doubt this bad press is not good at all for them to make their own targets. The Congressional Budget Office has estimated 7 million people we're going to sign up in the exchanges through March, and 106,000 is really far away from 7 million. But again, it is a six-month enrollment period, so we'll see how it unfolds.

MARTIN: But as we know, there is a political component to this as a number of the states have declined to expand their Medicaid programs to accommodate some of these new enrollees. And a very large number of those states are - they had the authority to opt out because of the Supreme Court decision last year. What are people in those states going to do? What are they supposed to do? I mean, if the governors of those states that - we're not participating, what are they supposed to do?

CAREY: The biggest challenges are exactly in those states where the federal market is there because in a state like - let's take a state like California that has embraced the law, right, actively embrace it - lots of state-funded outreach, lots of state-funded navigators to help people get through the system. If you're in a state that opposes the law, like in Texas, you're not going to have state-run efforts to help push enrollment. That's really where it's on the federal government and where it's on allies of the Obama administration to get out there and do the outreach. And that has absolutely proved to be a hurdle in those states.

MARTIN: Well, thank you again for keeping us posted on this important issue. Can I just ask you this as a person's who's been following this from the beginning, really, before this whole debate started. Are you surprised? Are you surprised by this?

CAREY: I'm not a tech expert, and I don't want to underestimate the difficulty of all the HealthCare.gov things, but I am kind of surprised because they worked so hard to pass this. I mean, I covered this through 2009, 2010 watching the uphill battle Democrats had to do and all the maneuvers, and the fact that it's hindered so much right now from a website, yeah, it does surprise me.

MARTIN: Well, particularly given that this administration, in a political sense, has demonstrated such a high degree of technical savvy from the first campaign, I guess. But once again, it shows the difference between politics and governance. So Mary Agnes Carey, senior correspondent at Kaiser Health News. Once again, that's a news service. It's not affiliated with Kaiser Permanente. She was here with us once again in our Washington, D.C. studios. Mary Agnes Carey, thanks so much for joining us once again.